Steroid Refractory Autoimmune Haemolytic Anaemia Secondary to Sarcoidosis Successfully Treated with Rituximab and Mycophenolate Mofetil

Hematological involvement in sarcoidosis: from cytopenias to lymphoma

INTRODUCTION

We present an updated overview of the hematological involvementassociated with sarcoidosis, including a management approach forcytopenias and revisiting the association with hematologicalmalignancies.

AREAS COVERED

Theetiology of cytopenias in sarcoidosis can be attributed to two majoretiopathogenic mechanisms: infiltration of hematopoietic organs suchas the spleen and bone marrow, and autoimmune-mediated cytopenias.With respect to the association with hematological malignancies, itrequires careful evaluation of patients from a chronologicalperspective. Patients must be classified into one of three pathogenicscenarios, including preexisting hematological malignancies,synchronous development of malignancy and sarcoidosis due to commonpredisposing factors, or sarcoidosis as a predisposing factor formalignancies.

EXPERT OPINION

The association between sarcoidosis and hematologic involvement isbest understood as a pathogenic continuum, with cytopenias andhematologic neoplasms intertwined due to various etiopathogenicmechanisms. These mechanisms include sarcoid infiltration ofhematopoietic organs, common predisposing immunogenetics for thedevelopment of autoimmune cytopenias and malignancies, and anincreased risk of neoplasm development in patients with autoimmunecytopenias. Collaboration among the main specialties involved in theclinical management of these patients is crucial for an earlymonitoring and management.

Rituximab for the Treatment of Refractory Cardiac Sarcoidosis-A Single Center Experience

OBJECTIVE

To examine the effect of anti-B cell therapy (rituximab) on cardiac inflammation and function in corticosteroid-refractory cardiac sarcoidosis.

BACKGROUND

Cardiac sarcoidosis (CS) is a rare cause of cardiomyopathy characterized by granulomatous inflammation involving the myocardium. While typically responsive to corticosteroid treatment, there is a critical need for identifying effective steroid-sparing agents for disease control. Despite growing evidence on the role of B-cells in the pathogenesis of sarcoidosis, there is limited data on the efficacy of anti-B cell therapy, specifically rituximab, for controlling CS.

METHODS

We reviewed the clinical experience at a tertiary care referral center of all patients with CS who received rituximab after failing to improve with initial immunosuppression therapy, which included corticosteroids. Fluorodeoxyglucose positron emission tomography (FDG-PET/CT) images before and after rituximab treatment were evaluated. All images were interpreted by 2 experienced nuclear medicine trained physicians.

RESULTS

We identified seven patients, (5 men, 2 women; mean age at diagnosis, 49.0±7.9 years) with active cardiac sarcoidosis who were treated with rituximab. The median length of follow-up was 5.1 years. All individuals, but 1, had received prior steroid-sparing agents in addition to corticosteroids. Rituximab was administered either as 1000 mg IV x 1 or x 2 doses, separated by 2 weeks. Repeat dosing, if appropriate, was considered after 6 months. All tolerated the infusions well.Inflammation as assessed by maximum SUV on cardiac FDG PET/CT uptake significantly decreased in 6 of 7 patients (median 6.0 to 4.5, Wilcoxon signed rank z: -1.8593, W: 3), whereas left ventricular ejection fraction improved or stabilized in 4 patients but decreased in 3. Mean left ventricular ejection fraction (LVEF) was 40.1% and 43.3% before and after treatment respectively (p=0.28). Three patients reported improved physical capacity, and 5 patients showed improved arrhythmic burden on Holter monitoring or ICD interrogation. One patient subsequently developed fungal catheter-associated infection and sepsis requiring discontinuation.

CONCLUSIONS

Rituximab was well tolerated and appeared to decrease inflammation, as assessed by cardiac FDG PET/CT scan, in all but 1 patient with active CS. These data suggest that rituximab may be a promising therapeutic option for CS, which deserves further study.

The critical role of histology in distinguishing sarcoidosis from common variable immunodeficiency disorder (CVID) in a patient with hypogammaglobulinemia

Background

Common variable immunodeficiency disorders (CVID) are a rare group of primary immune defects, where the underlying cause is unknown. Approximately 10–20% of patients with typical CVID have a granulomatous variant, which has closely overlapping features with sarcoidosis.

Case presentation

Here we describe a young man who sequentially developed refractory Evans syndrome, cauda equina syndrome and most recently renal impairment. Following immunosuppression, he has made a recovery from all three life-threatening autoimmune disorders. As the patient was hypogammaglobulinemic for most of the time while on immunosuppression, vaccine challenges and other tests were not possible. Histological features were in keeping with sarcoidosis rather than the granulomatous variant of CVID. In the brief period when immunosuppression was lifted between the cauda equina syndrome and renal impairment, he normalised his immunoglobulins, confirming sarcoidosis rather than CVID was the underlying cause.

Conclusion

We discuss diagnostic difficulties distinguishing the two conditions, and the value of histological features in our diagnostic criteria for CVID in identifying sarcoidosis, while the patient was hypogammaglobulinemic. The key message from this case report is that the characteristic histological features of CVID can be very helpful in making (or excluding) the diagnosis, particularly when other tests are not possible.